Form 36084 - Certification Of Records - Department Of Correction, State Of Indiana
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1CERTIFICATION OF RECORDS
State Form 36084 (R2 / 2-99)
I, _______________________________________________________________________________________, officially
designated as keeper of the Records for the ________________________________________________________, Indiana
Department of Correction, 302 West Washington Street, Room E334, Indianapolis, Indiana, do hereby certify that the attached
document(s), numbered ____________________________________________________, and listed below, is/are true and
correct copy(ies) of the record of ________________________________, Number _____________________, as these records
are numbered in this office.
In witness thereof, I hereunto subscribe my name and affix the seal of Indiana Department of Correction on this
____________ day of _____________________________________________, ______.
Signature
ATTACHED DOCUMENTS
Name of requestor
Title or agency
Address of requestor (street and number, city, state, ZIP code)
Date signed (month, day, year)
County of
}
SS:
State of Indiana
On this _______________ day of _____________________________________________, ____________, before me came
____________________________________________ to me known to be __________________________________________
of the Indiana Department of Correction, and acknowledged the execution of the foregoing instrument.
Signature of Notary Public
Name of Notary Public (typed or printed)
Date signed (month, day, year)
County of residence
Date commission expires
DISTRIBUTION:
White - Requestor;
Canary - Offender file;
Pink - Central Office file
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